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Tobacco Cessation and Behavioral Health. Pauline Chan, CalMEND Gary Tedeschi, California Smokers’ Helpline Kirsten Hansen, Center for Tobacco Cessation. Why Now?. Partnership CalMEND CPCI Integration of Primary Care and Mental Health CDPH California Tobacco Control Program

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tobacco cessation and behavioral health

Tobacco Cessation and Behavioral Health

Pauline Chan, CalMEND

Gary Tedeschi, California Smokers’ Helpline

Kirsten Hansen, Center for Tobacco Cessation

why now
Why Now?
  • Partnership
    • CalMEND
      • CPCI
        • Integration of Primary Care and Mental Health
    • CDPH
      • California Tobacco Control Program
        • California Smokers’ Helpline
why now cont
Why Now? (cont.)
  • Promotion of health and wellness
  • Changing philosophy around addictions & co-occurring treatment
  • Putting the “T” back in ATOD
  • Increased treatment effectiveness
  • A key component of the recovery process
  • You are in the best position to offer these services
a wellness philosophy
A Wellness Philosophy
  • To assist people to lead meaningful lives in their communities, we need to promote behaviors that lead to health
tobacco s deadly toll
Tobacco’s Deadly Toll
  • 435,000 deaths in the US/year
  • 4.8 million deaths worldwide/year
  • 10 million annual deaths estimated by year 2030
  • 50,000 annual deaths in the US due to second-hand smoke exposure


tobacco s deadly toll cont
Tobacco’s Deadly Toll (cont.)
  • 200,000 of the 435,000 annual deaths are people with mental illness and substance use disorders
  • For patients in treatment for alcohol and drug dependence, more than half die from tobacco-caused illnesses¹
  • Among treated narcotic addicts, smokers’ death rates are 4 times that of nonsmokers²

¹Hurt et al., 1996 ²Hser et al., 1994; Lynch & Bonnie, 1994

morbidity and mortality10
Morbidity and Mortality
  • Persons with mental illnesses die up to 25 years earlier and suffer increased medical comorbidity
      • Often from tobacco related diseases
  • Smokers with mental illnesses have increased hospitalizations and require higher dosages of medications
  • (Brown et al., 2000; Colton & Manderscheid, 2006; Dixon et al., 1999; Joukamaa et al., 2001; Osby et al., 2000; Dalack & Glassman, 1992; Desai, Seabolt, & Jann, 2001; Goff, Henderson, & Amico, 1992; Williams & Ziedonis, 2004; Ziedonis, Kosten, Glazer, & Frances, 1994).
Quittingsmoking is arguably the most important modifiable risk factor for cardiovascular diseaseAmerican Heart Association and CDC
who smokes
Who Smokes?
  • California adult smoking prevalence is 13.3%* ~ 4 million smokers
    • American Indian – 28.2%**
    • African American – 18.7%**
    • White – 16.2%**
    • Hispanic – 12.8%**
    • Asian/Pacific Islander – 12.0%**

* California Department of Health Services, 2007

** California Health Interview Survey, 2005

smoking and behavioral health
Smoking and Behavioral Health
  • About 41% of people with mental illness & substance use disorders smoke.²
  • Rates of smoking are 2-4 times higher than among the general population.¹
  • 60% of current smokers report having had a mental health or substance use diagnosis sometime in their lifetime.¹
  • This population consumes 45% of cigarettes smoked.³

1. Kalman, 2005 2. Lasser, 2000, 3. Breslau, 2003 and CDC 2010

smoking by diagnosis
Smoking by Diagnosis

% Smoking

None Maj. Dep. S-phrenia Alcohol Anxiety Drug Abuse Bipolar

Lasser et al., 2000

smoking by diagnosis variety of surveys settings
Smoking by Diagnosis (variety of surveys & settings)

Beckham et al., 1995; De Leon et al., 1995; Farnam 1999; Grant et al., 2004; Hughes et al., 1996; Lasser et al., 2000; Morris et al., 2006; Pomerleaue et al., 1995; Stark & Campbell, 1993; Ziedonis et al., 1994

barriers vulnerabilities
Barriers & Vulnerabilities
  • Biological factors
  • Barriers to tobacco interventions
    • Systems Factors
    • Clinician Factors
    • Client/Consumer Factors
  • Tobacco industry targeting
biological factors
Biological Factors
  • Persons with behavioral health diagnoses may have neurobiological features that:
    • increase their tendency to use nicotine,
    • make it more difficult to quit, and
    • complicate the withdrawal phase.
  • Nicotine enhances
    • concentration
    • information processing
    • learning
    • mood
  • May reduce medication side effects
barriers to tobacco interventions systems factors
Barriers to Tobacco Interventions: Systems Factors
  • Competing demands
  • Tobacco as socialization activity, behavioral reward
  • Staff acceptance and promotion
  • Not part of current treatment milieu
  • Lack of reimbursement for services

Barriers to Tobacco Interventions: Clinician Factors

  • Expectation of failure
  • Competing demands
  • Fear of symptom exacerbation & relapse
  • Lack of training
  • Minimization
smoking prevalence among mental health providers
Smoking Prevalence Among Mental Health Providers
  • 30% - 35% of mental health providers smoke as compared to-
    • Primary Care Physicians 1.7%
    • Emergency Physicians 5.7%
    • Registered Nurses 13.1%
    • Dentists 5.8%
    • Dental Hygienists 5.4%
    • Pharmacists 4.5%
  • Strouse, Hall, Kovac, 2004
barriers to tobacco interventions client consumer factors
Barriers to Tobacco Interventions: Client/Consumer Factors
  • Expectation of failure
  • Lack of knowledge
  • Fear of withdrawal symptoms
  • Fear of weight gain
  • Concern about recovery
  • Concern about stress management (tension, anxiety)
  • Doubt about dealing with boredom
  • Part of daily routines
  • Integral to social activity

“I’ve been schizophrenic since I was 14. I was told more or less when I went to the hospitals that cigarettes help control certain areas in my brain and the way we function out in society. I became more of a smoker because I was told it would help me with my illness. I was taught more about it helping my illness than I was about cancer and stuff like that.”

- Consumer focus group participant

  • Morris et al, 2009
tobacco industry targeting
Tobacco Industry Targeting
  • Monitored or directly funded research supporting the idea that individuals with schizophrenia were:
    • less susceptible to the harms of tobacco
    • that they needed tobacco as self-medication
  • Promoted smoking in psychiatric settings by:
    • providing cigarettes and
    • supporting efforts to block hospital smoking bans

Prochaska JJ, Hall SM, Bero LA., 2007


Myths and

Myth-breaking Evidence

myth 1
Myth #1
  • Myth: Persons with mental illness and substance use disorders don’t want to quit smoking.
  • Fact: The majority of persons with mental illness and substance use disorders want to quit smoking and want information on cessation services and resources.
interest in quitting results behavioral health
Interest in Quitting Results: Behavioral Health
  • Study of 300 depressed smokers: 79% were interested in quitting. (Prochaska, 2004)
  • Study of 224 hospitalized psychiatric patients who smoke: 79% of eligible smokers recruited into the study (Prochaska et al., 2009)
  • Review of clinical trials: 50% - 77% in substance use facilities were interested in quitting. (Joseph, 2004)
myth 2
Myth #2
  • Myth: Persons with mental illness and substance use disorders can’t quit smoking.
  • Fact: Persons with mental illness and substance use disorders can successfully quit using tobacco.
smoking cessation results mental illnesses
Smoking Cessation Results: Mental Illnesses

Most combine meds & psycho-education +/or CBT

  • Schizophrenia: 8 studies (n= 9-70)

Quit rates 35-56% post-treatment,

12% at 6-months

  • Depression: 8 studies (n= 29-615)

Quit rates 31-72% post-treatment,

12-46% at 12 months

(el-Guebaly et al., 2002)

does abstinence from tobacco cause recurrence of psychiatric disorders
Does Abstinence from Tobacco Cause Recurrence of Psychiatric Disorders?
  • For depressed smokers who quit :
    • No increase in suicidality, hospitalization, use of marijuana, stimulants, or opiates
    • Less alcohol use among those who quit (Prochaska et al., 2008)
  • For smokers with schizophrenia who quit:
    • No worsening of attention, verbal learning/ memory, working memory, or executive function/inhibition, or clinical symptoms of schizophrenia (Evins et al., 2005 )
myth 3
Myth #3
  • Myth: Smoking cessation will threaten recovery for persons with substance use disorders.
  • Fact: Smoking cessation can enhance long-term recovery for persons with substance use disorders.

(Prochaska et al., 2004; Saxon, 2003; Signal Behavioral Health, 2008; Lemon et al. 2003; Gulliver et al 2006; Ziedonis et al, 2006; Baca & Yahne, 2009)

smoking cessation results during addictions treatment or recovery
Smoking Cessation Results: During Addictions Treatment or Recovery
  • Systematic review of 17 studies
  • Smokers with current and past alcohol problems:
    • More nicotine dependent
    • Less likely to quit in their lifetime
    • As able to quit smoking as individuals with no alcohol problems

Hughes & Kalman, 2006, Drug Alc Dep

does abstinence from tobacco cause relapse to alcohol and illicit drugs
Does Abstinence from Tobacco Cause Relapse to Alcohol and Illicit Drugs?
  • At > 6 months follow-up, tobacco treatment with individuals in addictions treatment was associated with a 25% increased abstinence from alcohol and illicit drugs
  • Caveat – one well done study looking at concurrent vs. delayed tobacco cessation treatment (n=499; Joseph, et al, 2004)
      • Comparable smoking quit rates at 18 months, but lower prolonged alcohol abstinence rates for concurrent treatment group at 6 months

Prochaska et al., 2004

behavioral health professionals
Behavioral Health Professionals
  • Often the clinician for whom contact is the most frequent and who knows the client/consumer best
  • Able to coordinate pharmacotherapy and behavioral/counseling treatment
  • Trained in mental health and/or substance abuse treatment
  • Able to identify and address any changes in psychiatric symptoms during the quit attempt.

Adapted from Prochaska, 2009

clinical practice guidelines
Clinical Practice Guidelines
  • Comprehensive, evidence-based approach for smoking cessation
  • Released in June 2000 by the U.S. Public Health Service-updated version in 2008
  • Systematic approach to tobacco cessation for all healthcare facilities

Clinical Practice Guidelines (cont.)

  • All patients/clients should be screened for tobacco use, advised to quit and be offered intervention
  • Those trying to quit should be offered pharmacotherapy, unless contraindicated
  • There is a dose response relationship with the amount of contact provided
evidence based model the 5 a s
Evidence-Based Model: The 5 A’s

Ask:Systematically identify all tobacco users at every visit

Advise: Advise tobacco users to quit

Assess: Assess each tobacco user’s willingness to quit

Assist: Assist tobacco users with a quit plan

Arrange: Arrange follow-up contact


The 5 A’s and A, A, R

Ask:Systematically identify all tobacco users at every visit

Advise:Advise smokers to quit

Refer to the California Smokers’ Helpline and/or Peer-to-peer counselor

Assess:Assess each smoker’s willingness to quit

Assist:Assist smokers with a quit plan

The Helpline provides behavior modification counseling (quit plan and quit date)

Arrange:Arrange follow-up contact

The Helpline provides 5 follow-up calls – timing is based on the probability of relapse.

california smokers helpline 1 800 no butts
California Smokers’ Helpline1-800-NO-BUTTS
  • Free statewide tobacco cessation program
  • Funded by tobacco taxes
    • Propositions 99 & 10
  • Scientifically proven to be effective
  • All services available by telephone
  • In operation since 1992
  • Adults, teens, pregnant women and proxy
  • Multiple languages
multiple languages
Multiple Languages
  • English1-800-NO-BUTTS (1-800-662-8887)
  • Cantonese1-800-838-8917
  • Korean1-800-556-5564
  • Mandarin1-800-838-8917
  • Spanish1-800-45-NO-FUME (1-800-456-6386)
  • Vietnamese1-800-778-8440
available services
Available Services
  • Self-help materials
  • Referral lists of local cessation programs
    • Updated by each county’s tobacco control program
  • Individual telephone counseling
      • Confidential
      • One pre-quit call, multiple proactive follow-up calls
      • Trained counseling staff
helpline counselors
Helpline Counselors
  • Bachelor level or higher in psychology, social work, or health related field
  • Majority are bilingual/bicultural
  • Training & quality control
    • 48-hour, in-house training
    • 1-month apprenticeship
    • Clinical supervision
    • Continuing education

© California Smokers’ Helpline


Follow-Up Evaluation



Motivate smokers to call




A Randomized, Controlled Trial





Source: California Smokers’ Helpline


Quit Attempts by the 3 Groups

Made a Serious Quit Attempt








Single Counseling

Multiple Counseling

Source: Zhu et al. (1996), JCCP, 64, 202-211

relapse curves for the 3 groups
Relapse Curves for the 3 Groups

Source: Zhu et al. (1996), JCCP, 64, 202-211

what happens in each call
What Happens in Each Call?
  • Initial session
    • Comprehensive, 30-40 min. call
    • Preparation to quit
    • Setting a quit date
  • Follow-up sessions
    • Up to five 10-15 min. calls
    • Relapse prevention
    • Pharmacotherapy review
first session
First Session
  • Treatment overview & rationale
  • Motivation
  • Health considerations
  • Smoking & quitting history
  • Quitting methods
  • Environmental considerations
  • Self-efficacy
  • Self-image
  • Planning
  • Call summary
  • Setting a quit date
  • Addressing follow-up calls

Source: Zhu S-H, Tedeschi GJ, Anderson CM, Pierce JP. J Couns Devel 1996;75;93-102.








Relapse-Sensitive Scheduling

Percent abstinent

0 1





Days after quitting

Source: Zhu & Pierce (1995), Prof. Psych. Res.& Practice, 26, 624-625

proactive follow up sessions
Proactive Follow-up Sessions
  • Quit status
  • Withdrawal review
  • Pharmacotherapy review
  • Challenges & smoking events
  • Motivation & self-efficacy
  • Support
  • Planning for future
  • Self-image

Source: Zhu S-H, Tedeschi GJ, Anderson CM, Pierce JP. J Couns Devel 1996;75;93-102.

helpline intervention summary
Helpline Intervention Summary






  • Identify a strong reason
  • Bolster belief in ability
  • Develop a solid plan
  • Adopt a new view of self
  • Keep trying

Helpline Callers with

Behavioral Health Issues

self reported behavioral health issues among helpline callers
Self-Reported Behavioral Health Issues Among Helpline Callers
  • Do you have any current mental health issues such as:
    • An anxiety disorder?
    • Depression?
    • Bipolar disorder?
    • Schizophrenia?
    • Drug or alcohol problem?
      • If yes, have you been actively using/drinking in the last month?
self reported behavioral health issues among helpline callers55
Self-Reported BehavioralHealth Issues Among Helpline Callers

% Smoking

(Zhu,et al, 2009. Unpublished data)


Quitting Success

30-Day Point Prevalence (%) at 2 Months

No Mental Illness



Mental Illness

* Descriptive data, not based on results of a randomized controlled trial

(Zhu,et al, 2009. Unpublished data)

conclusions from the helpline
Conclusions from the Helpline
  • Smokers with mental illnesses call in high numbers
    • Across all demographics
  • They appear to be more motivated
    • More likely to get counseling & use NRT
  • The motivation and use of treatment seem to compensate for the vulnerability associated with their mental health condition.
  • As a result, they are equally likely to try to quit & succeed
  • Randomized controlled trials are needed to determine efficacy of telephone counseling for smokers with mental illnesses
treatment mi sud fundamentals
Treatment: MI/SUD Fundamentals
  • Demonstrated interest in quitting across populations
  • Smoking cessation rarely jeopardizes stability of primary disorder or recovery
  • Similar treatment/relapse prevention techniques
determining readiness to proceed
Determining Readiness to Proceed
  • Motivation
    • “Interested” is sufficient
    • Not ruling out some type of intervention, even if motivation to quit now is low
  • Stability
    • Need to be psychiatrically stable-do not need to be in full remission
unique tobacco treatment needs
Unique Tobacco Treatment Needs
  • Involve primary care/other health care providers
  • Determine need for more intensive behavioral therapy
  • Address psychotropic medication issues
  • Tailor treatment plan based on
    • Current stability of symptoms/recovery
    • Functional status
    • Current psychotropic medications
    • Previous quit history
helpline counseling considerations
Helpline Counseling Considerations
  • Psychiatric stability
    • How are the client’s symptoms?
    • Is the client in treatment?
    • How consistent is the client with treatment & how is it working?
  • No major life changes
  • No major medication changes
  • No active intoxication/withdrawal from other substances
counseling considerations cont
Counseling Considerations(cont.)
  • Quitting history & symptoms
    • Past quit attempts are helpful indicators of what to expect.
    • What changes in symptoms were noticed?
  • Biochemical factors
    • Nicotine acts much like a psychotropic medication on brain chemistry.
    • The blood levels of some the medications can increase dramatically when quitting.
    • Medications may need to be adjusted.
counseling considerations cont64
Counseling Considerations(cont.)
  • Content, length, & number of calls
    • Based on level of functioning and professional support
  • Counselor style
    • How much direction vs. facilitation should a counselor provide?
counseling considerations cont65
Counseling Considerations(cont.)
  • Client contact with prescribing MD
    • Refer back to the primary physician
  • Professional support & referral
    • May need to help clients identify support in their local area
role of nicotine receptors
Role of Nicotine Receptors
  • Chronic nicotine use results in permanent increase in the number of receptors.
  • The brain gets used to a new, "nicotine normal” level.
  • Reduced nicotine use (e.g. quitting smoking) disrupts “nicotine normal” receptor activity; causes nicotine withdrawal symptoms.
  • Without nicotine, receptor activity normalizes again in 3-6 months, but increase in receptors remains indefinitely.
  • Increase in receptors is responsible for:
    • Difficulty reducing amount smoked.
    • Quick relapse to former levels of smoking
withdrawal symptoms
Withdrawal Symptoms
  • Depressed mood
  • Sleep disturbance
  • Irritability, frustration or anger
  • Difficulty concentrating
  • Anxiety
  • Restlessness
  • Decreased heart rate
  • Increased appetite or weight gain
  • Craving

American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.) Washington, DC.

pharmacotherapy options
Pharmacotherapy Options
  • Nicotine Replacement Therapy (NRT)
        • Nicotine Patch (OTC)
        • Nicotine Gum (OTC)
        • Nicotine Lozenge (OTC)
        • Nicotine Inhaler
        • Nicotine Spray
  • Medication
        • Bupropion SR (Wellbutrin SR, Zyban)
        • Varenicline (Chantix)
        • Other: Nortriptyline, Clonidine
nicotine replacement therapy
Nicotine Replacement Therapy
  • Used to help smokers get off nicotine slowly. Nicotine is released into the bloodstream (via the type of NRT) in order to help reduce physical withdrawal symptoms.
  • NRT works by replacing some of the nicotine from smoking at the receptor sites with nicotine from less harmful sources.
  • Reduced efficacy for women over time, unless paired with high intensity support (Cepeda-Benito et al., 2004).

Contraindications: pregnancy or nursing, recent heart attack, irregular heart beat, severe or worsening heart pain, stomach ulcers, overactive thyroid, high blood pressure, diabetes requiring insulin.

bupropion wellbutrin s r zyban
Bupropion (Wellbutrin S-R, Zyban)
  • Bupropion (Zyban) is a non-nicotine prescription drug, the sustained-release form of the antidepressant Wellbutrin.
    • The “pill” is thought to stimulate dopamine and norepinephrine, brain chemicals that give smokers the sensation of alertness & energy.
    • Reduces the withdrawal symptoms such as cravings, irritability and depressed mood.
    • Works equally well for men and women.

Contraindications: seizure disorders, cranial trauma, stroke, withdrawing from alcohol, current or prior diagnosis of bulimia or anorexia nervosa, pregnancy/nursing, other meds like MAO inhibitors

varenicline chantix
Varenicline (Chantix)
  • Varenicline (Chantix) is a non-nicotine prescription drug developed specifically for smoking cessation. Not an antidepressant.
    • The “pill” releases dopamine, but substantially less than with smoking.
    • Varenicline specifically targets the alpha-4 beta-2 (α4β2) nicotinic receptors, blocking the binding of nicotine from smoking.
    • Reduces the urge to smoke and reduces the pleasure derived from smoking.
    • Works equally well for men and women.

Contraindications: < age 18, pregnancy/nursing, caution if psychiatric disorder, renal impairment, other meds like insulin, blood thinners, asthma puffers

varenicline chantix73
Varenicline (Chantix)
  • Post-marketing reports of adverse mood and behavior changes.
  • Available research data has been reviewed and causal links have not yet been established.
  • Warnings are for both patients and providers to closely monitor psychiatric symptoms of anyone taking varenicline to stop smoking.
  • Studies are underway to test varenicline in patients with MI.
boxed warning for chantix zyban
Boxed Warning for Chantix & Zyban
  • July 1, 2009 – FDA announced it is requiring manufactures to use a Boxed Warning
  • It will highlight the risk of serious issues including:
    • Changes in behavior
    • Hostility & agitation
    • Depressed mood
    • Suicidal ideation, behavior, & attempts
  • The FDA also stated - the risk of serious adverse medication events must be weighed against significant health benefits of quitting smoking

Six Month Point Prevalence Quit

Rates for FDA-Approved Cessation Medications









(2.5, 3.8)

Percent quit



(1.2, 1.7)



(1.7, 2.2)



(1.7, 3.0)



(1.5, 2.9)



(1.8, 2.2)

Nicotine lozenge: (single study results) 2 mg = OR 2.0 (1.4, 2.8) 4 mg = OR 2.8 (1.9, 4.0)

*PHS Clinical Practice Guideline, May 2008.

on the horizon nicotine vaccine
On the Horizon: Nicotine Vaccine
  • In Phase III trials: Will take a few more years.
  • Works by stimulating immune system to produce antibodies to nicotine + protein molecule
  • Antibodies then bind to any nicotine in bloodstream; can’t pass the blood/brain barrier
  • Effects of nicotine can’t reach brain
pharmacotherapy guidance for behavioral health
Pharmacotherapy Guidance for Behavioral Health
  • Smokers with behavioral health diagnoses who are trying to quit should receive pharmacotherapy (PHS Clinical Practice Guideline, 2008)
  • Dose level and duration of drug treatment individualized.
  • Many will need
    • Higher doses
    • Combination treatments
    • Longer duration of treatment
bupropion sr
Bupropion SR
  • Effective in smokers with Major Depression but relapse high when treatment discontinued
  • Not appropriate as only medication in Anxiety disorders
  • Effective in smokers with PTSD (limited evidence)
  • Effective in smokers with Schizophrenia but relapse high when treatment discontinued
bupropion sr cont
Bupropion SR (cont.)
  • Contraindicated in seizure and eating disorders
  • Not recommended
    • Alcohol abuse/dependence
    • Bipolar disorder
    • Extended sleep deprivation
    • Past head trauma
  • Interferes with efficacy of protease inhibitors used for HIV/AIDS treatment
  • Anecdotal reports of effectiveness for MI/SUD
    • One study in UK; positive results
    • Gap in the varenicline evidence base
  • Post marketing adverse behavior and mood changes
    • Have been reported in all samples
    • Boxed warning for neuropsychiatric issues, BUT still widely used by individuals with these issues
  • Providers need to closely monitor mental status of anyone quitting smoking on varenicline
pharmacotherapy guidance
Pharmacotherapy Guidance
  • Smoking induces CYP1A2 isoenzyme
  • Approximately doubles clearance of
    • Antipsychotics: Prolixin (fluphenazine), Haldol (haloperidol), Zyprexa (olanzapine), Clozaril (clozapine), Thorazine (chlorpromazine)
    • Antidepressants: Elavil (amitriptyline), Aventyl (nortriptyline), Jaminine (imipramine), Anafranil (clomipramine), Sinequan (doxepin), Fluvox (fluvoxamine)
  • Cessation may produce rapid, significant increase in blood levels
  • Need to monitor for increased side effects
clinical monitoring recommendations
Clinical Monitoring Recommendations
  • Patients should be seen 1-3 days after initiating smoking cessation
  • Monitor weekly for the 1st 4 weeks for BH relapse and the need to adjust medication levels
  • After 1st month, monthly review for 6 months
  • Communication between the primary care provider and BH provider(s) should occur
    • During the initiation of the cessation attempt
    • During the cessation period if any psychiatric complications occur
coverage for tobacco dependence treatments
Coverage for Tobacco Dependence Treatments
  • Health insurance coverage & requirements vary by plan
  • Medi-Cal provides FREE pharmacotherapy with:
    • Certificate of enrollment in behavior-modification, e.g. 1-800-NO-BUTTS
    • Prescription
  • Medicare
    • Prescription drug benefits – Part D
    • Reimburses for cessation counseling
    • CPT Codes:
        • 99406 (3-10 minute intervention)
        • 99407 (>10 minute intervention)

For free copies go to:


American Lung Association in CA

Center for Tobacco Cessation

Smoking Cessation Leadership Center

Nicotine Anonymous


Kirsten Hansen, MPP

Pauline Chan, PharmD

Gary Tedeschi, PhD